Name:___________________ ________________________ Date of Birth:_____________________________________ Highest Educational Level:__________________________ Todays Date: _____________________________________

SMI

(Version 1.1)

INSTRUCTION: Listed below are statements that people might use to describe themselves. Please rate each item based on how often you believe or feel each statement in general using the frequency scale.
FREQUENCY: In general 1= Never or Almost Never 2= Rarely 3= Occasionally 4= Frequently 5= Most of the time 6= All of the time

Frequency

In general... 1. I demand respect by not letting other people push me around. 2. I feel loved and accepted. 3. I deny myself pleasure because I dont deserve it. 4. I feel fundamentally inadequate, flawed, or defective. 5. I have impulses to punish myself by hurting myself (e.g., cutting myself). 6. I feel lost. 7. Im hard on myself. 8. I try very hard to please other people in order to avoid conflict, confrontation, or rejection. 9. I cant forgive myself. 10. I do things to make myself the center of attention. 11. I get irritated when people dont do what I ask them to do. 12. I have trouble controlling my impulses. 13. If I cant reach a goal, I become easily frustrated and give up. 14. I have rage outbursts. 15. I act impulsively or express emotions that get me into trouble or hurt other people.

February 2009 revision

FREQUENCY: In general 1= Never or Almost Never 2= Rarely 3= Occasionally 4= Frequently 5= Most of the time 6= All of the time

Frequency

In general... 16. Its my fault when something bad happens. 17. I feel content and at ease. 18. I change myself depending on the people Im with, so theyll like me or approve of me. 19. I feel connected to other people. 20. When there are problems, I try hard to solve them myself. 21. I dont discipline myself to complete routine or boring tasks. 22. If I dont fight, I will be abused or ignored. 23. I have to take care of the people around me. 24. If you let other people mock or bully you, youre a loser. 25. I physically attack people when Im angry at them. 26. Once I start to feel angry, I often dont control it and lose my temper. 27. Its important for me to be Number One (e.g., the most popular, most successful, most wealthy, most powerful). 28. I feel indifferent about most things. 29. I can solve problems rationally without letting my emotions overwhelm me. 30. Its ridiculous to plan how youll handle situations. 31. I wont settle for second best. 32. Attacking is the best defense. 33. I feel cold and heartless toward other people. 34. I feel detached (no contact with myself, my emotions or other people). 35. I blindly follow my emotions. 36. I feel desperate. 37. I allow other people to criticize me or put me down. 38. In relationships, I let the other person have the upper hand. 39. I feel distant from other people. 40. I don't think about what I say, and it gets me into trouble or hurts other people. 41. I work or play sports intensively so that I dont have to think about upsetting things.

February 2009 revision

FREQUENCY: In general 1= Never or Almost Never 2= Rarely 3= Occasionally 4= Frequently 5= Most of the time 6= All of the time

Frequency

In general... 42. Im angry that people are trying to take away my freedom or independence. 43. I feel nothing. 44. I do what I want to do, regardless of other peoples needs and feelings. 45. I dont let myself relax or have fun until Ive finished everything Im supposed to do. 46. I throw things around when Im angry. 47. I feel enraged toward other people. 48. I feel that I fit in with other people. 49. I have a lot of anger built up inside of me that I need to let out. 50. I feel lonely. 51. I try to do my best at everything. 52. I like doing something exciting or soothing to avoid my feelings (e.g., working, gambling, eating, shopping, sexual activities, watching TV). 53. Equality doesnt exist, so its better to be superior to other people. 54. When Im angry, I often lose control and threaten other people. 55. I let other people get their own way instead of expressing my own needs. 56. If someone is not with me, he or she is against me. 57. In order to be bothered less by my annoying thoughts or feelings, I make sure that Im always busy. 58. Im a bad person if I get angry at other people. 59. I dont want to get involved with people. 60. I have been so angry that I have hurt someone or killed someone. 61. I feel that I have plenty of stability and security in my life. 62. I know when to express my emotions and when not to. 63. Im angry with someone for leaving me alone or abandoning me. 64. I dont feel connected to other people. 65. I cant bring myself to do things that I find unpleasant, even if I know its for my own good. 66. I break rules and regret it later. 67. I feel humiliated. 68. I trust most other people. 69. I act first and think later. In general... 70. I get bored easily and lose interest in things. 71. Even if there are people around me, I feel lonely. 72. I dont allow myself to do pleasurable things that other people do because Im bad. 73. I assert what I need without going overboard. 74. I feel special and better than most other people. 75. I dont care about anything; nothing matters to me. 76. It makes me angry when someone tells me how I should feel or behave. 77. If you dont dominate other people, they will dominate you. 78. I say what I feel, or do things impulsively, without thinking of the consequences. 79. I feel like telling people off for the way they have treated me. 80. Im capable of taking care of myself. 81. Im quite critical of other people.

Frequency

February 2009 revision

FREQUENCY: In general 1= Never or Almost Never 2= Rarely 3= Occasionally 4= Frequently 5= Most of the time 6= All of the time

Frequency

82. Im under constant pressure to achieve and get things done. 83. Im trying not to make mistakes; otherwise, Ill get down on myself. 84. I deserve to be punished. 85. I can learn, grow, and change. 86. I want to distract myself from upsetting thoughts and feelings. 87. Im angry at myself. 88. I feel flat. 89. I have to be the best in whatever I do. 90. I sacrifice pleasure, health, or happiness to meet my own standards. 91. Im demanding of other people. 92. If I get angry, I can get so out of control that I injure other people. 93. I am invulnerable. 94. Im a bad person. 95. I feel safe. 96. I feel listened to, understood, and validated. 97. It is impossible for me to control my impulses. 98. I destroy things when Im angry. In general... 99. By dominating other people, nothing can happen to you. 100. I act in a passive way, even when I dont like the way things are. 101. My anger gets out of control. 102. I mock or bully other people. 103. I feel like lashing out or hurting someone for what he/she did to me. 104. I know that there is a right and a wrong way to do things; I try hard to do things the right way, or else I start criticizing myself. 105. I often feel alone in the world. 106. I feel weak and helpless. 107. Im lazy. 108. I can put up with anything from people who are important to me. 109. Ive been cheated or treated unfairly. 110. If I feel the urge to do something, I just do it. 111. I feel left out or excluded. 112. I belittle others. 113. I feel optimistic. 114. I feel I shouldnt have to follow the same rules that other people do. 115. My life right now revolves around getting things done and doing them right. 116. Im pushing myself to be more responsible than most other people. 117. I can stand up for myself when I feel unfairly criticized, abused, or taken advantage of. 118. I dont deserve sympathy when something bad happens to me. 119. I feel that nobody loves me. 120. I feel that Im basically a good person. 121. When necessary, I complete boring and routine tasks in order to accomplish things I value. 122. I feel spontaneous and playful. 123. I can become so angry that I feel capable of killing someone. 124. I have a good sense of who I am and what I need to make myself happy.

February 2009 revision

FREQUENCY: In general 1= Never or Almost Never 2= Rarely 3= Occasionally 4= Frequently 5= Most of the time 6= All of the time

2008 Young, J., Arntz, A., Atkinson, T., Lobbestael, J., Weishaar, M., van Vreeswijk, M and Klokman, J. Unauthorized reproduction without written consent of the authors is prohibited. This version is equivalent to the Dutch 1.0 version. For more information, write: Schema Therapy Institute, 130 West 42nd St., Ste. 501, New York, NY 10036, or for the Dutch version: J. Lobbestael, Clinical Psychological Science, PO Box 616, 6200 MD Maastricht, the Netherlands (Jill.lobbestael@dmkep.unimaas.nl).

February 2009 revision